Fillable Member Submitted Claim Form for Medical Services (Blue Cross Blue Shield of North Dakota)

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Member Submitted Claim Form for Medical Services (Blue Cross Blue Shield of North Dakota)

On average this form takes 35 minutes to complete

The Member Submitted Claim Form for Medical Services (Blue Cross Blue Shield of North Dakota) form is 3 pages long and contains:

  • 2 signatures
  • 2 check-boxes
  • 131 other fields

Country of origin: US
File type: PDF

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29318540 • 12-19
Note: Incomplete claim forms will be returned and will delay the processing of the claim.
Member Instructions
1. Complete section 1 and sign form
2. Ask your physician, healthcare provider or medical service supplier to complete section 2
3. If any other health insurance made payment on the claim, please include a copy of the Explanation of Benets from
that payer
4. Submit completed form (sections 1 and 2) along with any receipts, itemized statements and proof of payment by:
• Fax: (701) 282-1888
• Mail: BCBSND
Attn: Medical Claims Department
4510 13th Ave S
Fargo, ND 58121
5. Retain copies of all documents for your records
Physician/Provider/Supplier Instructions
1. Complete section 2 and sign form
2. Return completed form to:
• Patient
• Blue Cross Blue Shield of North Dakota (BCBSND) by:
– Fax: (701) 282-1888
– Mail: BCBSND
Attn: Medical Claims Department
4510 13th Ave S
Fargo, ND 58121
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
Member Submitted Claim Form
for Medical Services
29318540 • 12-19
PICA
Section 1 –
Patient Information
Patient’s Name
Address
City State Zip
Phone Number Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Relationship to Insured
Self
Spouse
Child
Other
PICA
Insured Information
Insured’s Name
Insured’s ID Number Phone Number
Address
City State Zip
Patient’s or Authorized Person’s Signature
I authorize the release of any medical or other information necessary to process this claim.
Signature Date (MM/DD/YYYY)
Section 2 –
Physician or Supplier Information
Date of Accident (MM/DD/YYYY) Referring Physician NPI
For Local Use Only
Diagnosis Code(s)
Page 1 of 2
Member Submitted Claim Form
for Medical Services
4510 13th Avenue South, Fargo, North Dakota 58121
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association
Noridian Mutual Insurance Company
click to sign
signature
click to edit
29318540 • 12-19
Section 2 –
Physician or Supplier Information
Date(s) of Service
Place of
Service
Procedure, Services
or Supplies
(Explain Unusual
Circumstances)
Description of Services
Diagnosis
Pointer
Charges
Days
or
Units
Rendering
Provider
ID #
From
(MM/DD/
YYYY)
To
(MM/DD/
YYYY)
CPT/
HCPCS
Modier
Federal Tax ID Number
SSN
EIN
Patient’s Account Number Total Charge
Service Facility Location Information
Facility NPI
Billing Provider Information
Phone Number Billing NPI
Signature of Physician or Supplier Including Degrees or Credentials
Signature Date (MM/DD/YYYY)
Page 2 of 2
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signature
click to edit
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Member Submitted Claim Form for Medical Services (Blue Cross Blue Shield of North Dakota)

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Completed 10 June 2021

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